On the second day of the new year, the front page of the Courier Journal highlighted the fact that one of our local hospitals was third in the United States in the number of spinal fusions performed. Since the Louisville business community has identified generating healthcare revenues as a top long-term strategic priority, the headline could easily be interpreted as a success story. However, the full-page article by John Carreyrou and Yom McGinty reprinted from the Wall Street Journal was not very flattering. (The article is not present on the Courier Journal website, but is available on the Wall Street Journal’s.)
The article emphasized the multibillion-dollar annual market and the medical controversy over when and if this extremely expensive major surgery should be done. Also highlighted were the large amounts of royalty money paid by the manufacturers of surgical equipment directly to surgeons who make the decision to operate. The article reported that five of the surgeons at my local hospital received more than seven million dollars in less than a year from the manufacturer of the implants used in the surgery. This was in addition to the clinical charges billed. It was reported that total Medicare reimbursements for spinal fusion at my local hospital were almost $48 million. The article proposes, and I and would have to agree, that the amounts of money involved are enough to distort the medical decision-making process. Since the hospital and doctors involved are part of our academic medical center, one might also reasonably assume that young physicians in training will perceive these activities as the standard of care.
There is not room here today to summarize the medical literature pertaining to spine surgery for disc disease and arthritis. Suffice it to say, most national organizations of general physicians and rheumatologists are arguing for fewer operations than in the past. In my own career as a rheumatologist, I personally recommended spine surgery for only three patients with arthritis. It is possible for you to suspect that I think too much spine surgery is being done in general. The hospital and doctors involved will likely offer their own explanations: indeed I think they will need to.
What I do want to talk about today, is the methodology that brings such observations to the forefront. It has been called study of “small area variations.” You see these kind of studies all the time. They were popularized by Dr. Jack Wennberg and the group at Dartmouth. I have always been drawn to this approach because the mapping of results appeals to my visual sense. For example, here is one of the earliest health policy studies I ever did. Continue reading “Area Variation. Is Doing the Most a Good Thing?”